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James, a 50 year old man, was seen in the Accident and Emergency Department of Newham General Hospital on 30 June 2000. He had woken up that morning with very sharp continuous pain going down from the top to the back of his head at his neck. He had vomited on two occasions.

The SHO (Senior House Officer) examined James and found that he was well and not distressed by the pain.

He was experiencing some neck stiffness and tenderness. The SHO diagnosed musculoskeletal neck pain. James was sent home with analgesia.

On 2 July 2000 at 3.15am, James once again attended the A&E Department at the same hospital, complaining of a severe headache, vomiting and neck stiffness. A diagnosis of a subarachnoid haemorrhage was considered.

On examination, it was noted that James was alert, conscious but disorientated. He was referred to the medical team for further investigation.

The differential diagnoses were musculoskeletal pain or viral meningitis. James was admitted for pain relief and a lumbar puncture in the morning if his pain did not settle.

Three days later, a CT scan was requested, but this was not performed until the next morning. At 5.50pm on 4 July, James collapsed. He stopped breathing for 30 seconds and was intubated.

At this point, the CT scan was located. It showed a possible sentinal bleed or anterior aneurysm. A further CT scan was ordered, which confirmed the diagnosis of subarachnoid haemorrhage.

It was too late for surgery, so James continued to be ventilated for a few hours in order to allow his family to see him. He died at 2.20pm on 6 July.

Our accident and emergency expert was critical of the failure to act on the history of sudden onset of severe headache with neck ache and vomiting; the severe neck stiffness and the failure to refer on to the medical team for further investigation and management.

Our expert also considered that on the second visit there was a failure to undertake intensive investigations, particularly by CT scan.

Our expert neuro-surgeon was also critical of the delay in diagnosing the subarachnoid haemorrhage and with appropriate treatment, James would have been alive and well today.